National Library for Health, Mental Health Specialist Library
Primary Care guidelines, adapted from www.mentalneurologicalprimarycare.org
Chronic mixed anxiety and depression
Chronic mixed anxiety and depression - F41.2 (Clinical term: Mixed anxiety and depressive
disorder Eu41.2)
Many people in the community report significant levels of depression and/or anxiety that do not
meet the diagnostic criteria for either depressive episode or the anxiety disorders. There are a
variety of ways of classifying this group within ICD-10, including dysthymia, mixed anxiety and
depression.
Presenting complaints
One or more physical symptoms (eg pains, poor sleep, fatigue), and various anxiety and
depressive symptoms, present for more than six months.
Diagnostic features
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Low or sad mood.
Loss of interest or pleasure.
Prominent anxiety or worry.
Multiple associated symptoms for example:
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disturbed sleep
disturbed appetite
tremor
suicidal thoughts or self-harm
fatigue or loss of energy
dry mouth
palpitations
tension and restlessness
poor concentration
irritability
dizziness
sexual dysfunction.
Differential diagnosis and co-existing conditions
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If
If
If
If
If
more severe depression or anxiety are present.
marked fear/anxiety in particular situations (eg crowds, enclosed spaces, travel).
history of manic episodes (eg excitement, elevated mood, rapid speech
somatic symptoms predominate without an adequate physical explanation
drinking heavi ly or using drugs
Copyright 2003-4 World Health Organization - UK Collaborating Centre www.iop.kcl.ac.uk/who
National Library for Health, Mental Health Specialist Library
Primary Care guidelines, adapted from www.mentalneurologicalprimarycare.org
Essential information for patient and family
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Anxiety and depression have many physical and mental effects that are likely to be worse
at times of personal stress. Aim to help the patient reduce symptoms.
The problems are not due to weakness or laziness.
Regular structured visits can be helpful - state their frequency and include arranged visits
to other professionals if necessary.
General management and advice to patient and family
1.
2.
3.
4.
If physical symptoms are present, discuss their link to mental distress.
Advise relaxation methods to relieve physical symptoms
Cut down caffeine intake (coffee, tea, stimulant drinks).
Discuss ways to challenge negative thoughts or exaggerated worries.
5.
Encourage simple cognitive strategies and structured problem-solving between
appointments:
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Identify events that trigger undue worry (eg a young woman presents with worry,
tension, nausea and insomnia which began after her son was diagnosed with
asthma. Her anxiety worsens when he has asthma episodes)
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List as many solutions as possible (eg meet the nurse to learn about asthma
management; discuss concerns with parents of other asthmatic children; write down
a management plan for asthma episodes).
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List the pros and cons of each possible solution.
At appointments, help the patient to:
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choose their preferred approach
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work out the steps necessary to achieve the plan
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set a date to review the plan; identify and encourage whatever seems to be working.
Assess risk of suicide.
Encourage use of self-help books, tapes and/or leaflets, and voluntary organizations (ref
1).
These patients risk developing more severe disorders and should be monitored regularly.
Medication
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Medication is a secondary treatment of uncertain value.
If prescribed, medication should be simple, reviewed regularly, and only continued if
definitely helping.
Avoid multiple psychotropics.
Can try a tricyclic or SSRI antidepressant if depression or anxiety are marked (ref
2) (BNF section 4.3.).
Copyright 2003-4 World Health Organization - UK Collaborating Centre www.iop.kcl.ac.uk/who
National Library for Health, Mental Health Specialist Library
Primary Care guidelines, adapted from www.mentalneurologicalprimarycare.org
Referral
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Stress/anxiety management, (ref 3) problem-solving, (ref 4) cognitive behaviour therapy
or counselling (ref 5,6) might help and be given in primary care or the voluntary sector. It
is unusual to refer for psychological treatment unless the disorder becomes severe.
Refer to secondary mental healthcare as an emergency if suicide risk is significant
Consider recommending voluntary/non-statutory/self-help organizations.
Resources for patients and families
Depression Alliance
England: 020 8768 0123
Wales: 029 2069 2891 (10am–4pm, Monday–Friday)
Scotland: 0131 467 3050
Website: http://www.depressionalliance.org
Provides information and support groups.
Aware Defeat Depression Ltd. (local groups) 02871 260 602
Email: info@aware-ni.org; website: http://www.aware-ni.org
Provides information leaflets, lectures and runs support groups for sufferers and relatives.
The Samaritans 08457 909090 (24-hour helpline; see telephone directory for local branches)
Website: http://www.samaritans.org.uk
The Samaritans offer confidential emotional support to any person who is despairing or suicidal.
SANEline 0845 767 8000 (12pm –2am)
Website: http://www.sane.org.uk
This is a helpline offering information and advice on all aspects of mental health for those
experiencing illness or their families or friends.
First Steps to Freedom 01926 851 608 (24-hour helpline)
Email: info@firststeps .demon.co.uk; website: http://www.first-steps.org
CITA (Council for Involuntary Tranquilliser Addiction) 0151 949 0102 (helpline 10am –1pm,
Monday–Friday; emergency weekend number available)
Offers advice on withdrawing from tranquilisers and help with anxiety and depression.
Leaflets are available from the Royal College of Psychiatrists (http://www.rcpsych.ac.uk): Worries
and Anxieties, Anxiety & Phobias, Anxiety
Helpi ng You Cope: A Guide To Starting And Stopping Tranquillisers and Sleeping Tablets by the
Mental Health Foundation: now out of print, but available online:
http://www.mentalhealth.org.uk/page.cfm?pagecode=PBBF
Anxiety, Phobias and Panic Attacks: Your Questions Answered by Elaine Sheehan, Vega Books,
2002
Information and advice on types of anxiety and the treatments available, including self-help
strategies and what to expect.
Living With Fear, 2nd edition, by Isaac M Marks. McGraw Hill, 2001. Tel: 01628 252 700; Email:
orders@mcgraw-hill.co.uk.
Copyright 2003-4 World Health Organization - UK Collaborating Centre www.iop.kcl.ac.uk/who
National Library for Health, Mental Health Specialist Library
Primary Care guidelines, adapted from www.mentalneurologicalprimarycare.org
This is a self-help manual.
Managing Anxiety and Depression by Nicholas Holdsworth and Roger Paxton. London: The
Mental Health Foundation, 1999. Publications, The Mental Health Foundation, 7th Floor, 83
Victoria Street, London SW1H 0HW. Tel: 7802 0304. http://ww.mentalhealth.org.uk
Restoring the Balance: A Self-Help Program for Managing Anxiety and Depression by Fred
Yates. London: The Mental Health Foundation, 2000. Publications, The Mental Health
Foundation, 7th Floor, 83 Victoria Street, London SW1H 0HW, UK. Tel: 020 7802 0304; we bsite:
http://www.mentalhealth.org.uk.
This is a self-help CD-ROM for people with mild to moderate anxiety and depression.
References
1 Consensus, plus some, usually small, trials. For example, Donnan P, Hutchinson A, Paxton R
et al. Self-help materials for anxiety: a randomized controlled trial in general practice. Br J Gen
Pract 1990; 40: 498-501. (BV). Audiotape and booklet is given to patients with chronic anxiety.
Intervention led to reduced scores for depression, as well as for anxiety.
2 Lima M, Moncrieff J. Drugs versus placebo for the treatment of dysthymia (Cochrane Review).
In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software. (AI) Fifteen studies were
analysed. There is some evidence of efficacy of most antidepressants in dysthymia (chronic, mild
depressive syndrome) that has been present for at least two years.
3 McLean J, Pietroni P. Self care - who does best? Soc Sci Med 1990, 30(5): 591-596. (BIII) This
describes a controlled trial of a general-practice-based class teaching self-care skills, relaxation,
stress management, medication, nutrition and exercise. Significant improvements were seen and
maintained after one year.
4 Catalan J, Gath DH, Anastasiades P et al. Evaluation of a brief psychological treatment for
emotional disorders in primary care. Psychol Med 1991, 21: 1013-1018. (BII) This paper
describes a small randomized control trial. Patients - selected for high symptom scores - did
significantly better with problem-solving therapy than with routine care. Other patients - with lower
symptom scores -who were not treated showed similar improvement to the treated group.
5 Roth AD, Fonagy P. What Works For Whom? A Critical Review of Psychotherapy Research.
New York: Guilford Press, 1996. (CII) This work concludes that the efficacy of counselling in
primary-care settings is difficult to assess because of the methodological problems of available
research. Counselling seems more appropriate for milder than for more severe disorders, and
evidence seems better for counselling focused on a particular client group (eg relationship or
bereavement counselling).
6 Bower P, Rowland N, Mellor Clark J et al. Effectiveness and cost-effectiveness of counselling in
primary care (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update
Software. (B1) Seven studies were analysed. Results showed that counselling is significantly
more effective than 'usual care' in the short- but not the long-term. Satisfaction with counselling
was high. Patients had a mix of 'emotional disorders'.
Copyright 2003-4 World Health Organization - UK Collaborating Centre www.iop.kcl.ac.uk/who